Fluid and Electrolytes: Acids and Bases

Tuesday, July 14, 2009

9:42 PM

• Fluid and Electrolytes Acids and Bases

• Julie Mann, RN, ACNP

• Some New Terms

○ Total body water
 Sum of all the water or fluids within all of the body
comparments in the pt. makes up 60% of body weight.
○ Intracellular fluid (ICF)
 Within cells 2/3 of total body water.
○ Extracellular fluid (ECF)
 Outside of cells 1/3 of total body water.
 Additionally there is sweat, urine.
○ Interstitial Fluid
 Fills the space around the cells and outside of blood
vessels.
○ Intravascular Fluid
 Fluid in the blood vessels (plasma)
• Osmolarity and Osmotic pressure
○ Osmolality: concentration of a solute per kilogram of water
 Primary electrolyte is sodium.
○ Osmolarity concentration of solute per liter of a solution.
 Creates osmotic pressure.
○ Osmotic Pressure: the pulling power of a solution for water.
○ Isotonic Solution: physiologically equivalent to blood plasma (no
osmotic diff, no shifting of fluids occurs) and other body fluids,
stay in ECF space. e.g. Normal Saline, ringers, lactated ringers.
 Replacing water.
○ Hypotonic: less concentrated solution
 Pull water out of vessels into cells. Increased cell water and
decreased vascular fluid. e.g. given if cells are dehydrated,
renal failure. D5 (5% dextrose) half normal saline, D5 water
(5% dextrose with water), drives water into cells.
Contraindicated for fragile neural cells, we don't like
swelling brains (cerebral edema). Have to be monitored.
○ Hypertonic: A more concentrated solution
 Given for drastically low sodium level or hypoglycemic
given D50 (50% dextrose), D10 (10% dextrose) newborn
with diabetic mother. Have to be monitored.
  e.g. high percentage saline
○ Hypotonic: A more dilute solution
• Oncotic Pressure
○ Oncotic pressure (colloid oncotic pressure): the pulling force
exerted by colloids in a solution
 Albumin - most important colloid for maintaining oncotic
pressure, helps maintain adequate vascular pressure. Sits
in vessels and pulls fluid into blood vessels.
 Administered for patients with third space fluid, draws
fluid back into vascular system so we can pee it out.
• Capillary filtration
○ Capillary hydrostatic pressure
 Pushing the water out of the capillary
 Fluid moves out of capillaries into tissues.
○ Capillary oncotic pressure
 Pulling water into the capillary
○ In artery CHP greater than COP fluid moves into tissues, in vein
COP greater than CHP fluid moves into vessels.
• Chemical Regulation of fluid balance
○ ADH (antidiuretic hormone)
 acts on distal tubules of the kidneys
 Secreted by posterior pituitary, regs water balance by
acting on distal tubules of the kidneys
 Increase in BP, rise in osmolality, kidneys get rid of more
water (neg feedback loops) Blood volume low, cause renal
tubules to not get rid of water.
○ Aldosterone
 Secreted from adrenal gland
 causes kidneys to secrete K+ instead of Na+
 Water follows sodium, helps body hang onto extra water
(neg feedback loop)
○ Glucocorticoids
 Cortisol, promote renal retention of Na+ and H2O
○ Atrial natriuetic peptide (ANP) and Brain natriuretic peptide
(BNP)
 released with high blood volume or blood pressure causing
vasodilation, trigger aldosterone and ADH to be released.
 Found in either atria or ventricles released into body when
atria or ventricle is stretched.
 There is a blood test for BNP
○ Thirst Mechanism
  When as much as 1 milliosmol/liter decrease in amount of
water needed.
 Triggers aldosterone and ADH.
 Depressed in elderly. More likely to experience dehydration.
• Alterations in Water balance
○ Dehydration
 More body water loss than taken in
○ Overhydration
 More body water taken in than loss.
• Alterations in Water Balance
○ Isotonic Alterations
 Amount gained/loss is proportion to electrolytes gain/loss
 Isotonic Fluid Loss
 Lose fluid and electrolytes at same rate - wound,
excessive diaphoresis.
 Isotonic Fluid Excess
 Gain fluid and electrolytes at same rate - over hydrate
with isotonic solution.
• Alterations in Water Balance
○ Hypotonic Alterations
 Osmolality of serum is less than should be (normal). Low
sodium level. Water and not enough electrolytes.
 Water Excess --> water toxicity
 Drinks too much fluid, hard to develop b/c body has
several compensatory mechanisms. Neurological
condition to drink large amounts of fluid, marathon
runners drinking only water.
 Confusion, convulsions, muscle twitching, headaches.
○ Hypertonic Alterations
 Osmolality is elevated above normal, more sodium than
water.
 Water Deficit
 Dehydration from pure water loss.
 Body can't concentrate urine, ie. lose large volumes of
fluid through kidneys, (diabetes) --> hypovolemia (low
blood volume)

Alterations in Sodium
• Sodium
○ Helps conduct neural impulses, helps reg K+, found in all body
fluids, neurological responses.
○ nml: 135 to 145 mEq/L (each lab has own normals)
 ○ Hyponatremia below 135
 Causes
 Renal disease
 Diuretics
 GI losses
 Skin Losses
 Wound drainage
○ Hypernatremia above 145
 Causes
 Decreased water intake
 Watery diarrhea
 Fever
 Hyperventilation
 Burns
 Increased sodium dietary intake
• What happens to people?
○ hyponatremia
• behavioral changes
 lethargy
 confusion
• depressed reflexes
• seizures
• coma
○ hypernatremia
• thirst
• fever
• dry mucous membranes
• restlessness
• Alterations in Potassium
○ Potassium, even small changes are poorly tolerated.
• Functions: maintains action potentials of muscles, assists in
controlling the cardiac rates/rhythms, conducts nerve
impulses.
○ nml: 3.5 to 5 mEq/L
○ Mechanisms of regulation
 renal regulation
 Kidneys maintain balance by excreting or reabsorbing
in glomerulus (mostly).
 Extra- and intra cellular shifts
 Temporary shift into RBC (hemoglobin), liver muscles,
bone
 ○ Hypokalemia
 Low intake in diet, excessive loss of K+ usually in gut
(suctioning), nausea/vomiting, sweating profusely, diabetes
encephalitis.
○ Hyperkalemia
 Excessive intake of potassium, usually body tolerates well
unless a lot given quickly, renal failure, potassium sparing
diuretics.
• What happens to the person
○ Hypokalemia
 Mild losses asymptomatic
 Well tolerated
 Acute Losses cause
 Skeletal Muscle Weakness
 Loss of smooth muscle tone
 Cardiac dysrhythmias
 Lethargy/Fatigue
 Inability to concentrate
○ Hyperkalemia
 Slow onset usually well tolderated
 Mild
 Restless ness
 Intesting cramping
 Diarrhea
 Severe: (see slide)
• Alterations in Calcium and Phosphorus and Magnesium
○ Vitamin D regulation
 Calcitriol - form of vit D makes Ca and Phosphorus available
for bone mineralization.
 Helps absorb Ca in intestine.
 Activates parathyroid hormone.
○ Parathyroid hormone regulation
 Helps increase blood calcium levels by transporting Ca out
of bones.
 Aid reabsorption in kidneys
 Raise serum Ca levels and lowers Phosphorus levels b/c
they have an inverse relationship with one another.
• Alterations in Calcium
○ Muscle contractions, clotting abil, neurological conduction,
rigidity to teeth/bones.
○ Normal level 8.5-10.5 mg/dl
○ Hypocalcemia
  Causes
 Hypoparathyroidism
 Hypomagnesemia
 Alkalosis
 Multiple blood transfusions
 Malabsorptive states
 Renal disease
○ Hypercalcemia
 Causes
 Hyperparathyroidism
 Hypophosphatemia
 Hyperthyroidism
 Vitamin D intoxication
 Steroid therapy
 Immobility
 Lithium therapy
• Alterations in Calcium
○ hypocalcemia
 Paresthesias (muscle pain)
 skeletal muscle cramps
 abdominal spasms and cramps
 hyperactive reflexes
 Hypotension
 bone pain, deformities, factures
○ hypercalcemia
 Polyuria (a lot of peeing), polydipsia (very thirsty)
 anorexia, n/v, constipation
 Ataxia (uncoordinated muscle movements)
 osteoporosis
 lethargy
 stupor, coma
 HTN - may be due to inabil of muscle cells to relax fully.
• Alterations in Phosphorus (Phosphate)
○ Inverse relationship with Ca, essential for muscular function,
important for RBC function, cellular metabolism, role in
formation of teeth/bones.
○ Normal level: 2.5 to 4.5 mg/dl
○ Hypophosphatemia
 From decreased absorption of Vit D, intestinal loss, less skin
absorption, diabetic ketoacidosis, alcoholic, poor dietary
intake.
○ Hyperphosphatemia
  From renal insufficiency, low blood calcium, chemotherapy,
parathyroid gland is understimilated, prolonged Vit D
exposure, antacids, salicylates, excessive intake of phos
supplements, massive transfusions of blood.
• Alterations in Phosphorus Manifestations
• Hypophosphatemia
○ Intention tremor
○ Ataxia, Paresthesias
○ Seizures
○ muscle weakness
○ bone pain
○ Osteomalacia (softening of bone)
○ bleeding disorders
○ impaired WBC fxn
• Hyperphosphatemia
○ paresthesias
○ Tetany (rigidity to muscles)
○ hypotension
○ cardiac arrhythmias
• Alteration in Magnesium
○ Usually a function of dietary intake, role in enzymatic process in
body, helps power Na/K pump (convert ATP to ADP), transmits
electrical impulses across nervous system and MSK, necessary
to release parathyroid hormone.
○ Normal level: 1.8 to 3.0 mg/dl
○ Hypomagnesia
 Chronic alcoholism (most common)
 Decreased dietary intake
 Decreased absorption d/t GI pathology
 Increased GI losses
 Increased Renal excretion
 Burns
○ Hypermagnesia
 Untreated diabetic ketoacidosis
 Adrenal insufficiency
 Mg++ treatment in preeclampsia (pregnancy induced HTN)
 Lithium ingestion
 Volume Depletion
• Alteration in Magnesium Manifestations
• hypomagnesia
○ personality change
 ○ nystagmus
○ tetany
○ tachycardia
○ hypertension
○ cardiac arrhythmias
○ + Babinski, Chvostek, and Trousseau signs
• hypermagnesia
○ Lethargy
○ Hyporeflexia
○ Confusion
○ Coma
○ Hypotension
○ Cardiac arrhythmias
○ cardiac arrest
• Acid Base Disturbances
• Acid-Base Balance
○ Must be regulated in a narrow range to function normally
○ Lungs, kidneys, and bone regulate the balance
○ Hydrogen ions maintain membrane integrity and speed
enzymatic reactions
○ Bicarbonate is maintained as well.
○ pH represents a power of hydrogen
○ pH < 7.4 is acidic, > 7.4 alkaline
• Buffers
○ Absorb excess H+ and OH-
○ Prevent significant change in pH
○ Exist as acid base pairs
○ Carbonic Acid Buffering (bicarb) [main system]
 Lungs and kidneys
 Changing rate of ventilation (blow off extra CO2 or retain)
 Retain bicarb or excrete extra in pee.
○ Protein Buffering (hemoglobin)
 CO2 loaded onto hemoglobin
○ Renal Buffering (phosphate)
 Secreting H ions in urine and reabsorbing bicarb in renal
tubules.
• Acid Base Disorders
○ Metabolic versus Respiratory
  Metabolic - produce and alteration in bicarb (hydrogen and
CO2 associates and disassociates to be moves through
system),
 Respiration - alteration in partial pressure of CO2, increase
or decrease in ventilation
○ Acidotic versus Alkalotic
 pH level
• Metabolic Acidosis
○ Decrease HCO3- with decrease pH
○ Causes
 Diabetic Ketoacidosis, kidney failure, aggressive suctioning
of the GI tract
○ Compensation in increased resp. rate (blow off CO2) Kussmaul
type respiration.
○ Treatment
 Treat underlying cause, replace fluid/electrolyte volume.
 Supplemental sodium bicarb if severe (IV)
• Metabolic Alkalosis
○ Increased pH due to primary excess of HCO3-
○ Causes
 Increase in intake of alkalotic solution (IV, oral [antacids]),
vomiting, binge purge.
○ Compensation
 Decrease respiratory rate and depth
 Kidneys bring down pH by excreting more HCO3 in urine
(basic urine).
○ Treatment
 With fluid replacements.
• Acid Base Imbalances
○ Metabolic Acidosis
 Early:
 HA (head ache)
 lethargy
 Severe:
 Coma
 Death
 Compensatory Mechanism
 Kussmaul respirations
○ Metabolic alkalosis
 Weakness
 Muscle cramps
  Hyperactive reflexes
 Tetany
 Shallow, slow respirations
 Confusion
 Convulsions
 Atrial tachycardia
• Respiratory Acidosis
○ impaired alveolar ventilation and increase in PCO2 along with
decrease in pH
○ Causes
 Respiratory disorder (pneumonia, pulmonary edema,
respiratory distress syndrome, damage muscles of chest
wall, extremely obese (limited movement of chest wall),
○ Compensation
 Conserve and generate bicarb in body
 Kidneys excrete H+.
○ Treatment
 Improve ventilation status (mechanical ventilator).
• Respiratory Alkalosis
○ decrease in PCO2 producing an elevated pH and increase in
HCO3-
○ Causes
 Anxiety attack (psychogenic hypoventilation), hypoxia
caused by some form of lung disease, problem with
stimilation to ventilate, problem with respiratory center of
brain, mechanical vent w/ incorrect vent settings.
○ Compensation
 Eliminated bicarb in kidneys, conserve H+
○ Treatment
 Underlying cause, supplemental oxygenation, change
ventilation settings, anxiety - reassurance.
• More Acid-Base Imbalances
○ Respiratory Acidosis
 First:
 Breathlessness
 Restlessness
 Apprehension
 Then:
 Lethargy
 Disorientation
 Muscle twitching
  Tremors
 Convulsions
 Coma
○ Respiratory Alkalosis
 Dizziness
 Confusion
 Tingling of extremities
 Convulsions
 Coma
 Deep rapid respirations are the primary symptom
• Serum lab values (will be posted on Moodle)